Provider First Line Business Practice Location Address:
19848 LASSEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATSWORTH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91311-5648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
747-746-4720
Provider Business Practice Location Address Fax Number:
747-204-3104
Provider Enumeration Date:
06/15/2026